TENNESSEE DEPARTMENT OF REVENUE RV-F1312601 (Rev. 3-21) Application for Special Amateur Radio License Plates PURPOSE: Pursuant to T.C.A. 55-4-225, an owner or lessee of a motor vehicle who is a resident of this state and who holds an unrevoked and unexpired official amateur radio station license issued by the Federal Communications Commission may apply to the department, through the county clerk, for issuance of a special purpose license plate under this part. The application shall be accompanied by proof of ownership of an amateur radio station license. INSTRUCTIONS: Complete this application in its entirety and attach a copy of your FCC Amateur Radio Operator License. Please do not send money with this application. Submit your completed application by mail to: Vehicle Services Division, 500 Deaderick Street, Nashville, TN 37242. A. APPLICANT INFORMATION: Name (print):______________________________________________________________________________________________________ Street Address:___________________________________________________________________________________________________ City:_____________________________________________________ State:_____________ Zip:__________________________________ County:_____________________________________________ Phone Number: _____________________________________________ B. PLATE INFORMATION: (NOTE: If you currently have an amateur radio plate, all additional plates will have a number at the end of the plate with a preceding space. If your call sign is six characters, there will be no spacing between the call sign and the number. The number indicates how many amateur radio plates you have.) List all (if any) currently assigned plates:_______________________________________________________________________ ____________________________________________________________________________________________________________________ Federal Communication Commission Call Sign:____________________________________________________________________ FCC Operator Privileges:___________________________________________________________________________________________ Effective Date:_______________________________________ Expiration Date:_____________________________________________ C. PLATE REQUEST: _____Quantity of Special Amateur Radio License Plates Indicate Plate Type: Auto Motorcycle D. CERTIFICATION STATEMENT: I certify that I am the recipient of the F.C.C. Amateur Radio Operator License referred to above (a copy of which is attached), that I am a resident of the State of Tennessee, and that I have been issued a Tennessee Certificate of Title or have applied for the same for the vehicle on which the special plate(s) herein requested will be registered. Applicant's Signature:__________________________________________________________________ Date:______________________.